Arsenic poisoning in children

　　1. Etiology

　　It is caused by taking drugs with excessive arsenic content, accidentally ingesting arsenic-containing pesticides or rodenticides, or consuming fruits and vegetables contaminated with arsenic. Maternal poisoning can lead to poisoning in the fetus and infants.

　　2. Pathogenesis

　　Arsenic is a protoplasmic poison with a strong affinity for the sulfhydryl groups of proteins. It can inhibit many sulfur-containing enzymes that play an important role in metabolism, causing obstacles in cellular respiration and oxidation, disrupting cellular energy metabolism, and increasing the permeability of capillary walls.

　　Soluble arsenic compounds can be absorbed through the digestive tract, respiratory tract, and skin, distributed throughout the body through the blood. During acute poisoning, they are mainly distributed in the liver and kidneys, easily accumulating in hair and nails, and excreted through urine and feces. Arsenic ions bind with the sulfhydryl and hydroxyl groups in the protein structure of enzymes within the body, causing enzymes to lose their activity, disrupting normal metabolism, leading to cell death, and damaging nerve cells, the heart, liver, and kidneys. It can also directly damage the walls of small arteries and capillaries, causing organ congestion and bleeding.

　　Hydrogen arsenide is the most potent hemolytic poison. It enters the human body through the respiratory tract. High concentrations of hydrogen arsenide entering the human blood circulation bind with hemoglobin to form hemoglobin peroxide, reducing the amount of reduced glutathione in red blood cells, causing acute intravascular hemolysis, which leads to acute renal failure due to massive hemolysis. In addition, it can cause damage to the liver, heart, brain, and lungs. Inhaling hydrogen arsenide in air at a concentration of 50mg/m3 can be fatal within 1 hour, and 30mg/m3 can cause severe poisoning.

　　Delayed onset neuropathy: After 1-3 weeks from the acute arsenic poisoning, when the above clinical manifestations have mostly subsided and recovered, patients may present with varying degrees of

　　Acute arsenic poisoning commonly presents with gastrointestinal symptoms in the early stage, including dryness, pain, burning, and tightness in the mouth and throat, hoarseness, nausea, vomiting, difficulty in swallowing, abdominal pain, and diarrhea, etc. Initially, the vomit contains stomach contents, followed by mixed with blood, mucus, and bile. Sometimes, small pieces of unabsorbed arsenic compounds may be present, and the vomit may have a garlic-like odor. Severe cases may resemble cholera, starting with the excretion of large amounts of watery stools, which later become bloody or milky, mixed with blood streaks. Dehydration, acidosis, and shock may occur quickly, accompanied by headache, dizziness, irritability, delirium, toxic myocarditis, and multiple myocarditis, etc. A few may have nosebleeds and skin hemorrhages. Severe cases may develop respiratory, circulatory, liver, and kidney dysfunction and central nervous system lesions within 24 hours to several days after poisoning, presenting with symptoms such as difficulty in breathing, convulsions, and coma. A few may experience shock or even death within 20 minutes to 48 hours after poisoning, while gastrointestinal symptoms are not prominent. Patients may have attacks of hemolytic disease, strong positive urinary urobilinogen, and hemolytic phenomena are common in arsenic hydride poisoning. In subacute poisoning, polyneuritis may occur, with abnormal sensations in the limbs, starting with pain and then numbness, followed by weakness, fatigue, and eventually complete or incomplete paralysis, presenting with wrist drop, foot drop, and disappearance of tendon reflexes; or difficulty in swallowing, speech, and breathing disorders. Due to vascular dysfunction, skin redness or erythema may occur occasionally. Chronic poisoning patients often show weakness, loss of appetite, occasional nausea and vomiting, constipation or diarrhea, etc., with slight yellowing of the sclera, pain in the renal area, severe yellowing of the skin and mucous membranes, decreased white blood cells and platelets, anemia, disorders in the production of red blood cells and bone marrow cells, and hair loss, stomatitis, rhinitis, nasal septum ulceration, perforation, skin pigmentation, hyperkeratosis of the skin on the palm and heel, loss of luster and flatness of the nails, becoming thin and brittle, and appearing white transverse stripes. X-ray examination shows substances that X-rays cannot penetrate in the gastrointestinal tract.

　　When producing arsenic compounds, they should be sealed and recovered. Strengthen the storage of arsenic compounds, especially arsenic trioxide (arsenic), which looks similar to flour and salt, and should be stored by专人 to prevent accidental ingestion and poisoning.

　　Production conditions should be improved, with increased automation, mechanization, and sealing. Strengthen personal protection; recover and purify various waste gases, waste water, and waste slag containing arsenic, strictly prevent environmental pollution; workers should undergo regular physical examinations every year, monitor urine arsenic levels; individuals with severe liver, nervous system, hematopoietic system, and skin diseases should not engage in arsenic work.

　　Diet and disease care: dietarily, avoid foods that may damage the liver and other foods, and eat light meals. Eat more blood-boosting foods such as jujube, animal liver, etc., which are rich in vitamins and antioxidants. Eliminate the patient's anxiety and pessimism. Encourage the patient more and give them confidence.

　　1. Urine examination

　　Urobilinogen positive, routine urine examination shows protein and red and white blood cells.

　　Urine arsenic levels rise, and after acute arsenic poisoning for several hours to 12 hours, urine arsenic levels increase significantly >2.67μmol/L (0.2mg/L, normal urine arsenic levels).

　　2. Arsenic in hair

　　The normal value is 0.025-0.1mg/10g, and after oral poisoning, 30 hours or 2 weeks later, arsenic in hair >1.33μmol/100g (0.1mg/100g).

　　3. Vomitus

　　Arsenic qualitative positive.

　　4. Blood examination

　　Blood tests may show a decrease in white blood cells, platelets, and anemia, with hemoglobin of 0.1mg/100ml being diagnostically significant. However, blood arsenic has little diagnostic value for arsenic poisoning because the biological half-life of arsenic is only 60 hours.

　　5. Bone marrow examination

　　Red blood cell and bone marrow cell production disorders may occur.

　　6. Nerve conduction study

　　Indicating neurogenic damage, the affected muscles have denervation potentials, and the conduction velocity of sensory and motor nerves is slowed down.

　　7. ECG examination

　　EKG abnormalities, common changes in T waves and S-T segments, indicating myocardial damage; various arrhythmias may occur.

　　1. After arsenic poisoning in children, green bean soup should be drunk, and dietary avoidance of foods that damage the liver and other foods should be avoided. It is recommended to have a light diet and eat more foods that enrich the blood, such as jujube, animal liver, etc., which are rich in vitamins and antioxidants. Eliminate the patient's anxiety and pessimism, encourage the patient more, and give them confidence.

　　2. In the diet, seafood such as seaweed, scallops, and shrimps also have high arsenic content, so seafood products should be controlled in the diet. If a large amount of seafood is eaten, try not to drink juice again.

　　1. Treatment

　　Acute oral poisoning should be induced immediately, and the stomach should be washed with warm water or saline. Then, take fresh iron hydroxide detoxification agent (mixing an equal amount of 12% ferrous sulfate solution and 20% magnesium oxide suspension, shake well before use) to form insoluble iron arsenate with arsenic, take one spoonful every 5 to 10 minutes until vomiting, and stop administration. If this medicine is not available, give medicinal carbon suspension, milk, or egg white water, and then use sodium sulfate or magnesium sulfate to induce diarrhea. Hemodialysis should be used when necessary. At the same time, use effective detoxification agents rapidly, such as sodium sodium thiosulfate (sodium bisulfite), sodium propyl sulfonic acid (sodium propyl sulfonic acid), and dimercaprol. Intravenous fluid replacement, diuresis promotes the excretion of toxic substances, and corrects the imbalance of water and electrolytes. For symptoms such as liver, kidney, gastrointestinal tract, neuritis, convulsions, and others, symptomatic treatment can be given. If there is severe hemolysis, blood transfusion can be performed. Abdominal and muscle pain can be treated with calcium gluconate injection.

　　Chronic poisoning, in addition to the above mercaptans, can also be given intravenous injection of 10% sodium thiosulfate, once a day.

　　2. Prognosis

　　Severe poisoning often leads to acute hemolysis, acute renal function failure, and damage to important organs such as the liver, heart, brain, and lungs, affecting the prognosis.